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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 41549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2 . WATER SUPPLY �2 <br /> Is water supplied by private well : Yes vo Is viell proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public Water: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FILL, MQSQUITQ OR VQTCJ E2rrN_ JA1 <br /> State possible vector potential ez necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . ec location existing :_ _ Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAPITTATION <br /> State any problems not previous) noted - <br /> 8 . <br /> ete.s . pOPULATION DENSITY <br /> Appx. No . People per sq . mi . <br />